NHA Billing & Coding - Ch 4 - Claims Processing/Compliance 2023

NHA Billing & Coding - Ch 4 - Claims Processing/Compliance adjudication - the process health plans follow to examine claims and determine payment audit - a review or formal examination of a provider's accounting or a patient's medical records carrier block - data entry area located in the upper right corner of the CMS-1500 that allows for a four line address for the payer clearinghouse - edits and routes electronic claims to the insurance carrier for payment CMS-1500 - claim form used to submit paper claims for services and procedures rendered by physicians and other health care professionals on an outpatient basis continuity of care - coordinating treatment and health services between patients' health care providers covered entities - health plans, health care clearinghouses, or health care providers that conduct health information in electronic form in connection with a transaction covered by HIPAA denied claim status - claim status indicating a claim has been processed, but contained incorrect or incomplete information; a claim may also be denied for medical necessity Durable Medical Equipment (DME) - According to CMS, DME is .."equipment that can withstand repeated uses; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in absence of illness or injury; and is appropriate for use in the home" DME s also referred to as durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) DMEPOS acronym for - Durable medical equipment, prosthetics, orthotics and supplies Electronic billing - the process of submitting medical claims electronically to an insurance carrier for reimbursement of services rendered by a health care provider Electronic Data interchange (EDI) - a secure system to system interchange of data in a standardized format EDI acronym for - Electronic Data Interchange eligibility verification - confirmation that the patient is entitled to benefits by verifying the name of the insurance carrier, the effective date of active coverage, policy information, group number, copayments, and deductible; typically performed before services are rendered. Employer Identification Number (EIN) - unique identifier issued by the Internal Revenue Service for employers as required by HIPAA Electronic Health Care Transactions and Code Sets EIN acronym for - Employer Identification Number first party - the insured guarantor - the party responsible for payment of services provided HIPAA Electronic Health Care Transactions and Code Sets - HIPAA standardization of electronic transactions of health care data, including data elements, standard code sets, unique health identifiers, security safeguards, and privacy standards. HIPAA National Identifiers - required identification systems for health care organizations and health care providers HIPAA Privacy Rule - HIPAA national standards that protect individuals' medical records and other personal health information; covers the use and disclosure of PHI HIPAA Security Rule - requires health care providers to establish safeguards ensuring the protection of PHI whenever transmitting any type of patient information via electronic transmission HIPAA X12 837 - aka Health Care Claim or Equivalent Encounter Information - HIPAA mandated electronic transaction standard for claims, usually called the 837 claim or the HIPAA claim Health Care Claim or Equivalent Encounter Information - aka HIPAA X12 837 - HIPAA mandated electronic transaction standard for claims, usually called the 837 claim or the HIPAA claim incomplete claim status - claim status indicating a claim is missing required information insurance carrier - the company that issues and assumes the risk of an insurance policy